ConnectiCare Benefits, Inc.

Complete this Producer Agreement and return it to:

ConnectiCare, Inc.
Attention: Broker Licensing
175 Scott Swamp Rd
Farmington, CT 06032

Fax appointment documents to 860.678.5224 or email them to ccibrokercommission@connecticare.com

If you have any questions, call the ConnectiCare broker licensing department at 860.674.5803.